Intraventricular hemorrhage prediction in premature neonates in the era of hemodynamics monitoring: a prospective cohort study

Abstract

Unstable hemodynamics and prematurity are the main players in intraventricular hemorrhage (IVH) development. Our objective was to study 8 the use of superior vena cava flow (SVCF), left ventricular output (LVO), and right ventricular output (RVO), and anterior cerebral artery (ACA) Doppler measures in prediction of IVH in the first week of life in preterm infant ≤ 32 weeks and birth weight ≤ 1500 g. This prospective cohort study was conducted in 55NICU of Alexandria University maternity hospital. Of 147 enrolled patients, 132 infants born ≤ 32 weeks GA and birth weight ≤ 1500 g were eligible for- the study. One hundred twenty-seven infants completed the study. Infants were scanned for ACA-RI using transfontanellar ultrasound, and SVCF, LVO, and RVO using functional echocardiography in the first 24 h after birth. Patients had another two scans on DOL3 and 7 to detect IVH development. Low SVCF and high ACA-RI significantly increased the risk of IVH using logistic regression models with OR, 3.16; 95%CI, 1.19–8.39; P = 0.02 and OR, 1.64; 95%Cl, 1.10–2.44; P = 0.02, respectively. Low SVCF and high ACA-RI significantly increased risk of catastrophic IVH P = 0.025 and 0.023, respectively. Combined use of low SVCF < 55 ml/kg/min and ACA-RI > 0.75 is predictor of IVH with sensitivity 40.8% and 82.1% specificity.Conclusions: There are strong relations between both low SVCF and high ACA-RI, and IVH development in premature neonates ≤ 32 weeks and birth weight ≤ 1500 g, with more significance towards catastrophic IVH. Admission RSS and LVO are the strongest factors affecting SVCF. Maternal anemia, patent ductus arteriosus size (mm/kg), and capillary refill time were significantly associated with high ACA-RI. These findings help in more understanding of pathophysiological factors affecting central perfusion that might affect the longer term neurodeveopmental outcome.Trial registration: This work was registered in clinical trial.gv no NCT05050032. What is Known:•Whether SVCF and RI-ACA can predict IVH in preterm neonates is still debatable. What is New:•Low SVC flow and high ACA-RI significantly increased risk of IVH, confirming the role of hypoperfusion-reperfusion cycle in IVH development. The most striking result that combined metrics using the cut-off value of < 41 ml/kg/min for SVCF and > 0.85 for ACA-RI “in the first day of life” can correctly reject the presence of IVH in 98% of patients “during the first week of life.”

The role of blood pressure variability indicators combined with cerebral blood flow parameters in predicting intraventricular hemorrhage in very low birth weight preterm infants

“…Multivariate logistic regression analysis found that SBP SD (OR: 1.480, 95%CI: 1.020–2.147) and ACA-RI (OR: 3.027, 95%CI 2.769–3.591) were independent risk factors for IVH in preterm newborns. This indicates that high BPV and ACA-RI status may play a critical role in the development of IVH in preterm infants, consistent with the research results of Da Costa et al ( 10 ) and Farag et al ( 35 ), which suggest that abnormal BP fluctuations based on optimal MABP and increased ACA-RI are closely related to IVH. ACA-RI > 0.79 with 55.1% sensitivity and 83.7% specificity, and SBP SD > 6.05 with 55.1% sensitivity and 79.1% specificity.…”

“…In premature infants, alterations in cerebrovascular hemodynamics and fluctuations in CBF velocity increase the risk of intracranial hemorrhage ( 34 , 35 ). At present, it is difficult to accurately evaluate CBF clinically.…”

“…The above research methods are relatively complex, and there are certain interfering factors in clinical operations. Cerebrovascular blood flow velocity and resistance index are important reference indicators for CBF in preterm newborns ( 35 , 38 , 39 ). Schneitz et al found that higher levels of ACA-RI are related to cerebral ischemia and hypoxia in premature infants ( 40 ).…”

The Early Hematological Profile and Its Variations: A Useful Tool in the Prediction of Intraventricular Hemorrhage in Extremely Preterm Infants

“…These findings are consistent with previous studies that have also supported this correlation [ 49 , 50 , 51 ]. Factors such as hypotension and hypercapnia can increase the risk of intraventricular hemorrhage (IVH) by affecting cerebral blood flow [ 52 ]. In our study, univariate regression analysis showed that infants with a gestational age of less than 26 weeks, a cord base excess (BE) of less than −8.23, an initial HCT level of less than 42.6%, and those who experienced hypercapnia and hypotension requiring treatment within the first few days of life were more likely to develop IVH, particularly severe IVH.…”

Effect of delayed cord clamping on cerebral hemodynamics in preterm infants

“…When cerebrovascular autoregulation function is normal, fluctuations in systemic pressure within a certain range would not lead to fluctuations in cerebral blood flow. Some studies have suggested that RI may be related to cerebrovascular autoregulation [ 14 ]. In this study, RI was in the normal range and the amount of placental transfusion in this study may be within the regulatory capacity of cerebral vessels.…”